Reviewed by: Gilbert Schmidt, MD | BrightView Medical Director
Published: August 2026 Updated: Septmeber 2026
A social media ad promises help for depression, anxiety, or other mental health concerns. A few clicks later, a potential patient may be answering screening questions, speaking with a medical provider remotely, and learning whether medication can be shipped directly to their home.
Increasingly, that medication may be ketamine.
The growth of telehealth has made many types of healthcare easier to access. For people who live far from medical providers, have transportation challenges, or struggle to attend traditional appointments, that can be an important benefit.
But the rapid growth of at-home ketamine treatment is also raising questions about what happens when access to a controlled substance becomes significantly easier than it once was.
Those questions are particularly important because ketamine can cause sedation, dissociation, changes in blood pressure, breathing problems, and other adverse effects, and it also has the potential for abuse and misuse. Federal regulators have specifically raised concerns about some compounded ketamine products being used at home without onsite medical monitoring.[1]
“The question is: What safeguards exist in that second system, and do they actually work?” Gilbert Schmidt, MD, Medical Director for BrightView Health.
Ketamine and Esketamine Are Not the Same Thing
One important distinction often gets lost in conversations about “ketamine therapy.”
Ketamine is an FDA-approved anesthetic and a Schedule III controlled substance. FDA-approved ketamine is administered by injection and is not FDA-approved to treat depression, anxiety, or any other psychiatric disorder.[2]
Healthcare providers may prescribe an FDA-approved medication for a use that has not been specifically approved by the FDA, commonly called “off-label” prescribing. Off-label prescribing itself does not mean that a treatment is inappropriate or illegal.
Esketamine, a chemical relative of ketamine marketed under the brand name Spravato®, is different. The FDA has approved the nasal spray for certain adults with depressive disorders.
Because of significant safety concerns, however, Spravato carries a boxed warning addressing sedation, dissociation, respiratory depression, abuse and misuse, among other risks. Patients receive the medication under the direct supervision of a healthcare provider and must be monitored for at least two hours after administration. The medication is available through a restricted FDA safety program known as a Risk Evaluation and Mitigation Strategy, or REMS.[3]
That creates an important contrast with another rapidly growing model of care: compounded ketamine prescribed for use at home.
What Is Compounded Ketamine?
Compounding involves preparing a medication to meet the needs of an individual patient. Compounded medications can serve an important medical purpose when an FDA-approved medication cannot meet a patient’s particular needs.
However, compounded drugs are not FDA-approved. That means the FDA does not review an individual compounded drug for safety, effectiveness, or quality before it reaches patients in the same way it reviews an approved medication.[4]
Compounded ketamine may be prepared in formulations such as lozenges or rapidly dissolving tablets and prescribed off-label for psychiatric conditions.
The FDA has warned patients and healthcare providers about potential risks associated with compounded ketamine, including oral formulations used for psychiatric conditions. The agency has expressed particular concern when patients take the medication at home without onsite monitoring for possible adverse effects.[1]
Those potential effects can include:
- Sedation
- Dissociation or feeling disconnected from oneself or one’s surroundings
- Changes in blood pressure
- Slowed breathing or respiratory depression
- Psychiatric reactions
- Urinary or bladder problems
- Misuse and abuse
This does not mean that every patient who receives compounded ketamine will experience these effects or that every clinician who prescribes it is practicing unsafely.
It does mean patients should understand that at-home compounded ketamine and FDA-approved esketamine administered in a certified healthcare setting operate under very different regulatory and monitoring structures.
Telehealth Has Changed How Controlled Medications Can Be Prescribed
The rapid expansion of telemedicine during the COVID-19 pandemic also changed how some controlled medications could be prescribed.
As of August 2026, the Drug Enforcement Administration and U.S. Department of Health and Human Services have extended certain telemedicine prescribing flexibilities through December 31, 2026.[5]
Under those rules, DEA-registered practitioners can, when applicable requirements are met, prescribe Schedule II through V controlled medications through audio-video telemedicine encounters without first conducting an in-person medical examination. Prescribers must still comply with DEA requirements as well as applicable federal and state laws.[5]
Ketamine is a Schedule III controlled substance.
The telehealth flexibility was designed in part to preserve access to care, particularly for people in rural and underserved communities and those facing mobility or transportation barriers. DEA has also acknowledged the need to balance that access with safeguards intended to prevent misuse and diversion.[5]
For patients, that balance can be difficult to see from a social media advertisement.
From a Social Media Ad to At-Home Treatment
The ease of that process is part of what prompted BrightView to examine the issue.
After encountering advertisements for at-home ketamine treatment on social media, a BrightView team member followed the enrollment process to better understand what a prospective patient might experience.
The process included two brief telephone screenings. The service also described ongoing communication by text with medical providers to assess treatment and determine whether dosage changes might be appropriate.
That individual did not take ketamine as part of the review.
One consumer’s experience cannot represent every telehealth ketamine provider, and requirements and clinical practices vary substantially among companies and clinicians.
But it raises a larger question for patients:
How can someone tell the difference between convenient healthcare and care that may not provide enough medical oversight?
FDA Is Paying Attention to Online Ketamine Sales
Federal regulators are also scrutinizing ketamine sold online.
On June 23, 2026, the FDA issued warning letters to multiple websites offering ketamine products. The FDA’s current internet pharmacy warning-letter database lists numerous ketamine-related sites receiving letters that day.[6]
In one warning letter involving ketamine troches, FDA said it had identified unapproved and misbranded ketamine products being offered online and cited risks associated with unapproved ketamine, particularly when appropriate medical supervision is absent. The agency specifically raised concern about the easy availability of unapproved ketamine products through the internet.[2]
There is an important distinction here.
An illegal website selling unapproved prescription drugs without appropriate controls is not the same thing as a licensed healthcare provider legally prescribing compounded ketamine through telehealth.
Patients should not assume they are equivalent.
However, the enforcement activity highlights a broader concern regulators share with clinicians: as consumer interest in ketamine grows, so does the importance of knowing who is prescribing it, where the medication comes from, what medical assessment occurred, and what happens if something goes wrong.
What Should You Ask Before Starting At-Home Ketamine Treatment?
Convenience should not replace informed medical decision-making.
Before starting ketamine treatment through an online service, patients can ask questions such as:
- Who is the healthcare professional evaluating me, and what are their credentials?
- Will I have a live medical evaluation before receiving medication?
- What medical and mental health conditions are you screening for?
- How will my current medications and substance use history be evaluated?
- Where will the medication be compounded and dispensed?
- What monitoring is required while I take it?
- Should another adult be present during treatment?
- What should I do if I experience severe sedation, breathing difficulty, confusion, an extreme increase in blood pressure, or another concerning reaction?
- How are dose increases determined?
- How frequently will I speak directly with a healthcare provider?
- How will you monitor for increasing use, misuse, dependence, or other problems?
- What happens if I decide I want to stop treatment?
Patients should also make sure their prescriber knows about all medications and substances they use, including alcohol, prescription medications, illicit substances, and other drugs that can cause sedation.
People With a History of Substance Use Should Be Especially Cautious
Ketamine’s potential therapeutic benefits and its potential for misuse can exist at the same time.
The FDA-approved prescribing information for esketamine specifically instructs clinicians to assess patients for the risk of abuse or misuse and notes that people with a history of drug abuse or dependence may be at greater risk.[3]
For someone who has experienced a substance use disorder, that history should be part of an open conversation with the clinician considering ketamine treatment.
It should not automatically exclude someone from receiving appropriate mental healthcare. It should mean the patient and provider carefully consider the benefits, risks, monitoring plan, and other available treatment options.
Access and Safety Do Not Have to Be Opposites
Telehealth has removed important barriers to healthcare, and ketamine and related treatments continue to be studied for their potential role in treating serious mental health conditions.
The concern is not that treatment has become easier to access.
The concern is whether clinical safeguards are keeping pace with that access.
When a treatment involves a controlled substance capable of causing significant physical and psychological effects, patients deserve to know who is overseeing their care, what safety measures are in place, and what will happen if their treatment does not go as planned.
An advertisement may be the beginning of a healthcare decision.
It should not be the end of the patient’s questions.
Sources
1. U.S. Food and Drug Administration. Compounding Risk Alerts: Potential Risks Associated With Compounded Ketamine Products, Including Oral Formulations, for the Treatment of Psychiatric Disorders. FDA continues to list its October 2023 ketamine safety alert among current compounding risk resources.
2. U.S. Food and Drug Administration. Warning Letter: ketaminetroches.com, June 23, 2026. The FDA states that ketamine is not approved for treatment of any psychiatric disorder and describes safety concerns surrounding unapproved ketamine products offered online.
3. U.S. Food and Drug Administration. Spravato (esketamine) Prescribing Information. Current prescribing information includes the boxed warning, REMS requirements, direct healthcare supervision, and monitoring for at least two hours following administration.
4. U.S. Food and Drug Administration. Compounding and the FDA: Questions and Answers. FDA states that compounded medications are not FDA-approved and do not undergo FDA premarket review for safety, effectiveness, or quality.
5. U.S. Drug Enforcement Administration. DEA Extends Telemedicine Flexibilities to Ensure Continued Access to Care. Current flexibilities extend through December 31, 2026, subject to federal and state requirements.
6. U.S. Food and Drug Administration. Internet Pharmacy Warning Letters. FDA’s database lists multiple ketamine-related websites that received warning letters dated June 23, 2026.
